Four Chamber View

Fetal Cardiac Imaging:
Improving Detection of
Congenital Heart Disease
Alfred Abuhamad, M.D.
Eastern Virginia Medical School
Types of Fetal Situs
Four Chamber View
What to look for:
•
•
•
•
•
•
Fetal situs
Cardiac position and axis
Ventricular situs, size & contractility
Atrial situs, size, foramen & pulmonary veins
Atrial & ventricular septae
Atrioventricular & semilunar valves
Types of Fetal Situs
Situs
Incidence
CHD
Solitus
Common
Not Increased
Inversus*
1/100
Slightly Increased
(0.3 – 5%)
Ambiguous
1/10,000
Increased
*: Kartagener syndrome in 20%
Situs Ambiguous
• Complex CHD
• Abnormalities in venous drainage
• Bowel malrotations and obstructions
• Splenic abnormalities
• Biliary tree abnormalities
• Bronchial tree abnormalities
Normal Situs - Chest
From: A Practical Guide to Fetal Echocardiography – Abuhamad, Chaoui
Normal Situs - Abdomen
From: A Practical Guide to Fetal Echocardiography – Abuhamad, Chaoui
Left Isomerism
Right Isomerism
Four Chamber View
Abdominal Circumference
One full rib on each side
One full rib on each side
Cardiac Position
• Levocardia
Levoposition
L
–Levoposition (right chest mass)
• Dextrocardia
–Dextroposition (apex points to mid or left)
–Dextroversion (apex points to right)
• Mesocardia
Dextroposition
Dextroversion
Dextroversion
Mesocardia
• Situs inversus
• Situs ambiguous
• Discordant atrioventricular
connection
Cardiac Axis
Mesocardia
• Transposition of great arteries
• Double outlet RV
• Laryngeal atresia
Four Chamber View
Right Ventricle
Left-axis deviation:
•TOF
•CoA
•Ebstein
Right-axis deviation:
•DORV
•AV septal defect
•Common atrium
Four Chamber View
Left Ventricle
Four Chamber View
From: A Practical Guide to Fetal Echocardiography – Abuhamad, Chaoui
Four Chamber View
Cardiac Chambers
A
HLHS
B
HLHS
18 weeks
Hypoplastic Left Heart Syndrome
From: A Practical Guide to Fetal Echocardiography – Abuhamad, Chaoui
C
30 weeks
Rhabdomyomas
Four Chamber View
Interventricular Septum
• 2/3 muscular, 1/3 membranous
• Endocardial cushion area
• True positives v/s False positives
Tuberous Sclerosis
Ventricular Septum
From: A Practical Guide to Fetal Echocardiography – Abuhamad, Chaoui
Ventricular Septum
Muscular
Ventricular Septum
From: A Practical Guide to Fetal Echocardiography – Abuhamad, Chaoui
Ventricular Septum
Muscular
From: A Practical Guide to Fetal Echocardiography – Abuhamad, Chaoui
Ventricular Septum
Ventricular Septum
Inlet
Muscular – Swiss-cheese
Ventricular Septum
Ventricular Septum
Perimembranous
Perimembraneous
Four Chamber View
Four Chamber View
Right Atrium
Left Atrium
Atriae
Pulmonary Veins
Total Anomalous Venous Return
Total Anomalous Venous Return
From: A Practical Guide to Fetal Echocardiography – Abuhamad, Chaoui
Supracardiac
Total Anomalous Venous Return
Total Anomalous Venous Return
Cardiac
Infracardiac
Atrioventricular Valves
Atrioventricular Valves
Tricuspid
Mitral
•2 leaflets
•2 papillary muscles
•3 leaflets
•3 papillary muscles
•More apical insertion
Color Doppler – 4-Chamber
Atrioventricular Valves
Normal
Diagnosis?
AV Canal
TS
Ebstein Anomaly
Ebstein Anomaly
Great Vessels
Aorta
•Points to right shoulder
•Gives head & neck vessels
•Aortic arch (candy cane)
Transverse Planes
Pulmonary
•Points to left shoulder
•Divides to right & left
•Ductal arch (hockey stick)
5-Chamber
F
E
D
C
B
A
L
5-Chamber
5-Chamber
Tetralogy of Fallot
Normal
Tetralogy of Fallot
TOF
Tetralogy of Fallot
Transposition of Great Arteries
Transposition of Great Arteries
Pulmonary Stenosis
Transverse Planes
3-vessel-trachea
F
E
D
C
B
A
L
From: A Practical Guide to Fetal Echocardiography – Abuhamad, Chaoui
3-vessel-trachea
3-vessel-trachea
PA
AAo
SVC
L
DA
Ao Arch
T
Isthmus
DAo
3-vessel-trachea
TOF
Hypoplastic left heart syndrome
HLHS
3 Vessel-Trachea View
Sagittal Planes
Bicaval
L
B
A
C
Bicaval
Aortic arch
Aortic arch
Ductal arch
Ductal arch
Fetal Cardiac Evaluation
• Asymmetry
- Size
- Contractility
• Blood flow patterns
• Great vessel relationship
• Multiple approach to anatomy
TGA
Ductal arch